Objectives: This study investigated the sugar consumption of financially-restricted Black women in Mangaung, South Africa.

Method: Five hundred women were selected randomly and divided into younger (25–34 years) and older (35–44 years) groups. Dietary intake, sociodemographic status, anthropometry and biochemical data were obtained. Total sugar (TS) and added sugar (AS) consumption were compared between older and younger women as well as sociodemographic, anthropometric and biochemical categories.

Results: AS intake contributed 12% and 13% of total energy intake in younger and older women, respectively. AS consumption was higher in younger women living in brick houses and those who possessed a microwave oven. In older women, it was higher in husband-headed households. Underweight women with the lowest body mass index had higher sugar consumption than overweight and/or obese women. Women with a lower body fat percentage had a higher AS consumption than women with a high body fat percentage. Sugar consumption was significantly lower in younger women with elevated serum lymphocyte counts. TS and AS consumption was higher in younger women with elevated serum glucose levels. Older women with elevated serum insulin had a significantly higher TS consumption compared to those with normal insulin concentrations.

Conclusion: The amounts of TS and AS consumed by women in this observational study were unlikely to contribute to overweight and/or obesity.

Contexte: La prévalence croissante de la cardiopathie coronarienne, du diabète de type 2, de l’obésité et de taux anormaux de lipides a soulevé la question d’une relation possible entre ces maladies et la consommation de sucre.

Objectifs: Cette étude a enquêté sur la consommation de sucre des femmes noires financièrement limitées à Mangaung en Afrique du Sud.

Méthode: Un groupe de cinq cents femmes ont été sélectionnées aléatoirement et divisé en deux groupes: les 25-34 ans et les 35-44 ans. Des données sur la consommation alimentaire, le statut sociodémographique, l’anthropométrie et la biochimie ont été recueillies. La consommation de Sucres Totaux (ST) et de Sucres Ajoutés (SA), les catégories sociodémographiques, anthropométriques et biochimiques ont été comparées entre les deux groupes de femmes.

Résultats: L’apport de SA représentait respectivement 12% et 13% de l’apport énergétique total des femmes jeunes et âgées. La consommation de SA était supérieure chez les jeunes femmes vivant dans des maisons en briques et chez celles possédant un four à micro-onde. Chez les femmes âgées, elle était supérieure dans les foyers où l’homme était le chef de famille. Les femmes maigres présentant l »indice de masse corporelle le plus faible avaient une consommation de sucre supérieure à celle des femmes en surpoids et/ou obèses. Les femmes présentant le taux de graisse corporelle le plus faible avaient une consommation de SA plus élevée que les femmes à taux de graisse corporelle élevé. La consommation de sucre était bien plus basse chez les jeunes femmes présentant une numération des lymphocytes sériques élevée. La consommation en ST et SA était supérieure chez les jeunes femmes présentant un taux de glucose sérique élevé. Les femmes âgées présentant un taux sérique d’insuline élevé consommaient bien plus de ST que celles présentant des concentrations normales d’insuline.

Conclusion: Il est improbable que les quantités de ST et de SA consommées par les femmes de cette étude d’observation aient contribué au surpoids et/ou à l’obésité.

When consumed primarily as whole grains, fruit and vegetables, carbohydrates not only provide the body with energy and micronutrients, but also reduce the risk of becoming overweight and obese.¹² However, carbohydrates that are provided from these foods are much more nutrient dense than those provided by added sugar (AS). Although an upper limit for sugar intake has not been set, a maximum of 25% or less of daily energy intake from AS has been suggested.³¹ The World Health Organization (WHO)¹⁴ advises an intake of AS not exceeding 10% of the total daily energy intake. In Western countries,^5,15 AS consumption exceeds the recommended guidelines. In this regard, the significant increase in the consumption of sugar-sweetened beverages overloaded with high-fructose corn syrups,^16,17,18 which are also added to several other manufactured products, has come under scrutiny.^18,19 Although sucrose and not high-fructose corn syrup is used to sweeten beverages and other foods in South Africa, both sugar and high-fructose corn syrup are more or less equal mixes of fructose and glucose molecules (covalently bonded into a disaccharide in the case of sucrose and a mix of free fructose and glucose in the case of high-fructose corn syrup), so that metabolically there should be no difference in their effect on the body.

Limited data on the total sugar (TS) and AS consumption of urban Black South Africans have been published. Urban Black adults from the Cape Peninsula, South Africa, have been shown to consume 47–52 g per day of AS,²⁰ whilst urban Black South African women habitually consume a mean of 94.2 grams of sugar per day, in contrast to their rural counterparts’ intake of 44.6 g per day.²¹ The South African Food Based Dietary Guideline, ‘Eat and drink food and drinks that contain sugar sparingly’,²² implies that within a diet supplying at least 55% of the daily energy intake in the form of various carbohydrate-rich foods, some room for the intake of sugar is allowed.²³

The global increase in the prevalence of coronary heart disease, type 2 diabetes, obesity and abnormal blood lipid levels, has prompted the question of a possible relationship between these conditions and the consumption of AS.²⁴

Whilst some authors contend that there is no substantial evidence that an increased intake of AS contributes to an increase in body mass index (BMI) or obesity,^17,25 others argue that the effect of sugar on obesity and other metabolic disorders needs to be explored further.³

This paper documents the possible link between TS and AS consumption, fat consumption, sociodemographic and anthropometric status and selected biochemical variables of urbanised Black women in Mangaung, in the Free State Province of South Africa.

The structured questionnaire employed to establish the sociodemographic status of the women included questions on the number of years residing in an urban area, smoking habits, household composition, marital status, highest level of education, employment status of the respondent or husband and/or partner, head of the household, household facilities and type and size of dwelling. The questionnaire was administered during a structured interview with each woman, with Sesotho and isiXhosa interpreters assisting the researchers. Interviews were conducted at the research centre at the Central University of Technology, Free State. A validated, culture-sensitive Quantitative Food Frequency Questionnaire (QFFQ), developed for the Transition and Health during Urbanisation of South Africans (THUSA) study conducted by the University of North West in South Africa, was used in order to determine dietary intake.²⁷ The questionnaire included traditional and Western foods and local foods commonly sold in the Mangaung area by food vendors. A detailed description of the methodology employed to determine dietary intake of energy and macronutrients has been published in a separate paper.²⁸

For the purpose of this study, TS consumption included foods containing sugar in its natural form and sugar added to foods and beverages. AS refers to sugar added to porridge or cereal, sweet spreads such as jam, honey or syrup used on bread, sugar added during the preparation of vegetables and sugar and condensed milk added to tea or coffee, fizzy drinks, snacks, desserts, sweets, biscuits, cakes, tarts, custard and condiments such as tomato sauce and chutney.

Standardised methods (of which the procedures have been described in separate publications from this study) were used to determine BMI,²⁹ body fat percentage³⁰ and biochemical values, applying calibration and quality control specimens as supplied by the manufacturers of the respective methods for HIV and other selected biochemical variables.³¹

The mean intake by mass of the 20 most frequently-consumed foods in the two age groups is presented in Tables 1 and 2 respectively. Foods and beverages are listed from 1 to 20 in sequence of popularity, with Number 1 in the Tables indicating the food most frequently consumed (in grams) by the total sample of women. Frequently-consumed foods were very similar for the two groups, with English tea, fresh and/or whole milk, maize porridge and coffee ranking highest on the list. White sugar and foods containing AS, such as fizzy drinks and cordials, appeared high on the list of popular foods consumed by women of both age groups.

AS consumption in married and unmarried women was very similar, ranging between a median of 69 g per day for older women and a median intake of 76 g per day for younger women. Table 3 summarises the sugar and fat consumption of women in different sociodemographic categories. The fat intake of married women in both age groups tended to be higher than that of unmarried women. In the older group, women from households headed by a husband had a significantly higher intake of TS and AS (p = 0.028 and p = 0.022, respectively). AS consumption was significantly higher in younger women who lived in brick houses (p = 0.035). Younger women who possessed a microwave oven had significantly higher TS and AS intakes (p = 0.030 and p = 0.007, respectively) and total fat intake (p = 0.033). In the older group, the difference was significant for total fat intake (p = 0.030).

Table 4 depicts the sugar and fat consumption of younger and older women and their respective anthropometric status categories. More than 90% of all women had a body fat percentage in the fat and overweight category. Both TS and AS consumption was higher in women with the lowest BMI, and as BMI increased, sugar consumption decreased. Women with the highest body fat percentage also had the lowest intake of both TS and AS.

Table 5 displays the association between the consumption of TS, AS and total fat and selected fasting biochemical variables. Younger women with elevated total lymphocyte counts consumed significantly less sugar than those with normal lymphocyte counts (p = 0.041 for TS and p = 0.013 for AS).

In the younger group, a significant difference in sugar and total fat consumption between women with low-, normal- and high levels of serum glucose was evident (p = 0.012, p = 0.049 and p < 0.001 for TS, AS and total fat, respectively). As blood glucose levels tended to increase, so did TS and AS consumption. The total fat intake of women with elevated glucose levels was also higher than those with low- or normal glucose levels. In the older group, a significant difference in TS consumption was found between women with normal and high insulin levels (95% CI -52.9; -12.6). In addition, the p-value (0.039) indicated an overall effect of TS intake on insulin levels. Furthermore, a significant difference in AS consumption between women with normal- and high triglyceride levels was evident (95% CI 8.8; 32.1). As triglycerides tended to increase, AS consumption decreased. The small number of older women with high triglycerides (n = 29) requires that these results be interpreted with caution.

Considering the excessive rates of AS consumption noted in the scientific literature,^5,15 the median intake of TS and the median intake of AS were lower than figures reported for other urban Black South African women.²¹ The contribution of 12% and 13% of AS, respectively, to the total daily energy intake of women of the two age groups was lower than the proposed maximum intake level of 25% TE from AS,¹³ but higher than the 10% of TE proposed by the WHO.¹⁴

The debate between sugar intake and body weight is a long-standing one. In Australia where obesity increased three-fold between 1980 and 2003, the per capita consumption of refined sugar decreased by 23% in the same period.²⁵ Analysing the mean intakes by mass of the 20 most frequently-consumed foods, it became clear that sugar intake was mostly represented by sweetened beverages, refined grains and, to a lesser degree, some fruits. It is worth mentioning that the median energy and carbohydrate intake in our larger study exceeded current recommendations, whilst median fibre intake was inadequate for all women as reported in a previous publication of our study.²⁸ In both age groups, most of the carbohydrates ingested ranked relatively high on the glycaemic index list,²⁸ seen as a determinant of higher body weight.¹² More than half of all women were either overweight or obese and the majority demonstrated an unfavourably high body fat percentage, associated with low levels of physical activity.³⁴ Our finding that both TS and AS consumption was higher in women with the lowest BMI is supported by other studies stating that high carbohydrate diets seem to be less detrimental, with little evidence of the adverse effect of sugar on body weight.²⁵ As with BMI, women with the highest fat percentage also had the lowest intake of both TS and AS. When considering absolute fat and sugar intakes, our results do not support an inverse relationship between sugar consumption and fat consumption. Fat consumption was similar to sugar consumption, with fat intake increasing as sugar intake increased. It should be noted that a large percentage of women included in the study were found to be HIV-infected (which was likely to impact on BMI, fat percentage and biochemical parameters). However, no significant differences in the TS, AS and fat intake of HIV-infected and HIV-uninfected women were found.

Educational status and income have been associated independently with AS consumption, implying that low income groups with a poor educational level include more AS into their diet.²⁴ Poverty and food insecurity are related to a diet deficient in fresh fruit and vegetables, lean meats and fish, but high in palatable fat and energy-dense food.³⁵ Lower-cost foods such as refined carbohydrates, AS and added fats are preferred food choices of those with a lower socioeconomic background.³⁶ In general, these energy-dense food sources have a lower satiety value and may lead to passive overeating and most probably weight gain.³⁷ In view of the lower socioeconomic background of the urbanised women in our study, younger women living in brick houses and those who possessed a microwave oven consumed significantly more sugar and total fat compared with women residing in informal housing. In the older group, a significant difference was observed between TS and AS intake in households headed by a husband. Although the participating women failed to report on their weekly or monthly income and unreliable results were obtained,²⁶ it is likely that these significant differences point toward a more substantial diet in women with a higher disposable income.

The focus of several original studies and review articles has been aimed at the relationship between sugar consumption and the metabolic syndrome. A recent review by Bray³⁸confirmed that the fructose found in refined foods and sugar-sweetened beverages appears to be responsible for most of the metabolic risk factors. An excessive consumption of nutritive sweetened beverages has been associated with an increased risk of type 2 diabetes and cardiovascular disease through an increase in body weight.³⁹ Stanhope et al.⁴⁰ showed that fructose-sweetened beverages promoted de novo lipid synthesis, dyslipidaemia, visceral adiposity and insulin resistance in overweight or obese adults in small-scale randomised controlled trials.

In two systematic reviews, one followed by a meta-analysis, Malik et al.^18,41 confirmed the link between an increase in sugar-sweetened beverage intake, weight gain and the metabolic syndrome. An analysis of American data collected between 1909 and 1997 established the positive relationship between the prevalence of type 2 diabetes and obesity, which proportionally increased with an increased refined carbohydrate intake.¹⁹ In the USA cohort Nurses’ Study II (1991–1999), weight gain and risk for type 2 diabetes were related positively with a regular consumption of sugar-sweetened beverages.⁴ Later data (1999–2006) revealed a correlation between the consumption of AS and blood lipid levels, with those adding more sugar to the diet being more prone to higher triglyceride levels and higher triglyceride:HDL cholesterol ratios.⁴² In our study, sugar consumption was not significantly different for women with low-, normal- or high levels of most blood measures, other than serum lymphocytes, glucose and insulin. Results from the 20 most frequently-consumed foods seem to indicate that the contribution of sugar-sweetened beverages (tea, fizzy drinks and cordials) toward sugar consumption was relatively high.

When reviewing short-term randomised controlled trials, Fried and Rao⁴³ concluded that sucrose and fructose tended to increase serum triacylglycerol levels, but other dietary factors such as the total carbohydrate intake, types of dietary fat, carbohydrate and fibre need consideration. When reporting on longer-term studies, they found no long-term association between sugar or total carbohydrate intake and cardiovascular risk. However, these authors reported that results from the CARMEN randomised controlled trial that lasted six months showed that a high glycaemic-loaded diet was linked to higher serum triacylglycerol levels and an increased risk of coronary heart disease in women.⁴³In the current study, no significant differences between sugar intake, obesity or elevated total cholesterol levels were found. In the younger group, sugar consumption was significantly higher in women with increased serum glucose levels, whilst in the older group, both sugar and fat consumption increased as serum insulin concentrations increased, but the difference was not significant. When reviewing several studies, Daly⁴⁴ concluded that despite the conflicting results regarding the role of sugar in glycaemic control and insulin sensitivity, extremely varying sucrose contents in the diet did not affect insulin sensitivity differently in overweight persons, which could also apply to our study.

Data collection of the dietary intake of individuals and groups remains complex and no method can be singled out as being the most perfect.⁴⁵ In order to best ensure reliability and validity of the TE, TS and AS intake results in the present study, specially trained and skilled postgraduate interviewers interviewers in the field of Nutrition and Dietetics conducted the structured interviews. The participating women were instructed about the value of their contribution toward the study and a valid and reliable nutrient database was used to analyse data. However, the problem of over- or underreporting of real dietary intake remains a reality and has to be considered when interpreting our study results on the dietary intake of the selected food items.⁴⁶ Although the results from the 20 most frequently-consumed foods seem to indicate that consumption of sugar from sugar-sweetened beverages was relatively high, the specific contribution of these drinks to sugar consumption was not determined.

Higher sugar consumption was associated with a lower BMI and fat percentage. However, an inverse relationship between reported absolute fat consumption and BMI was not found. Sugar consumption was not significantly different for women with low-, normal- or high levels of most blood measures, other than serum lymphocytes, glucose and insulin. Sugar consumption in the amounts ingested by the women included in this study did not have a negative impact on health as reflected by anthropometry and biochemical variables, indicating that there may be a threshold at which sugar consumption affects these parameters.

2. Popkin BM. Contemporary nutritional transition: determinants of diet and its impact on body composition. Proc Nutr Soc. 2011;70(1):82–91. http://dx.doi.org/10.1017/S0029665110003903, PMid:21092363, PMCid:PMC3029493

3. Popkin BM, Nielsen SJ. The sweetening of the world’s diet. Obes Res. 2003;11(11):1325–1332. http://dx.doi.org/10.1038/oby.2003.179, PMid:14627752

4. Schulze MB, Manson JE, Ludwig DS, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA. 2004;292(8):927–934. http://dx.doi.org/10.1001/jama.292.8.927, PMid:15328324

5. Lustig RH, Schmidt LA, Brindis CD. The toxic truth about sugar. Nature. 2012;482(7383):27–29. http://dx.doi.org/10.1038/482027a, PMid:22297952

6. Popkin BM, Gordon-Larsen P. The nutrition transition: worldwide obesity dynamics and their determinants. Int J Obes Relat Metab Disord. 2004;28(Suppl 3):S2–S9. http://dx.doi.org/10.1038/sj.ijo.0802804, PMid:15543214

7. Steyn NP, Bradshaw D, Norman R, et al. Dietary changes and the health transition in South Africa: implications for health policy. In: Food and Agriculture Organization (FAO) of the United Nations. The double burden of malnutrition. Case studies from six developing countries. Issue 84. p. 295–303. Rome: Food and Agriculture Organization; 2006.

8. Vorster HH, Bourne LT, Venter CS, et al. Contribution of nutrition to the health transition in developing countries: a framework for research and intervention. Nutr Rev. 1999;57(11):341–349. http://dx.doi.org/10.1111/j.1753-4887.1999.tb06911.x, PMid:10628185

9. Vorster HH, Margetts BM, Venter CS, et al. Integrated nutrition science: from theory to practice in South Africa. Public Health Nutr. 2005;8(6A):760–765. http://dx.doi.org/10.1079/PHN2005775, PMid:16236213

10. Vorster HH, Venter CS, Wissing MP, et al. The nutrition and health transition in the North West Province of South Africa: a review of the THUSA (Transition and Health during Urbanisation of South Africans) study. Public Health Nutr. 2005;8(5):480–490. http://dx.doi.org/10.1079/PHN2005784, PMid:16153329

11. Bourne LT, Lambert EV, Steyn K. Where does the black population of South Africa stand on the nutrition transition? Public Health Nutr. 2002;5(1A):157–162. http://dx.doi.org/10.1079/PHN2001288, PMid:12027279

12. Whitney E, Rolfes SR. Understanding nutrition. 12th ed. Belmont: Wadsworth; 2008.

13. Johnson RK, Appel LJ, Brands M, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2009;120:1011–1020. http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192627, PMid:19704096

14. World Health Organization. Diet, nutrition and the prevention of chronic diseases: Report of a Joint WHO/FAO Expert Consultation. Geneva, Switzerland: World Health Organization; 2003. p. 1–149.

15. Nguyen S, Lustig RH. Just a spoonful of sugar helps the blood pressure go up. Expert Rev Cardiovasc Ther. 2010;8(11):1497–1499. http://dx.doi.org/10.1586/erc.10.120, PMid:21090921

16. Guthrie JF, Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc. 2000;100(1):43–51. http://dx.doi.org/10.1016/S0002-8223(00)00018-3

17. Gibson S. Sugar-sweetened soft drinks and obesity: a systematic review of the evidence from observational studies and interventions. Nutr Res Rev. 2008;21(2):134–147. http://dx.doi.org/10.1017/S0954422408110976, PMid:19087367

18. Malik VS, Popkin BM, Bray GA, et al. Sugar- sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33(11):2477–2483. http://dx.doi.org/10.2337/dc10-1079, PMid:20693348, PMCid:PMC2963518

19. Gross LS, Li L, Ford ES, et al. Increased consumption of refined carbohydrates and the epidemic of type 2 diabetes in the United States: an ecologic assessment. Am J Clin Nutr. 2004;79(5):774–779. PMid:15113714

20. Bourne LT, Langenhoven ML, Steyn K, et al. Nutrient intake in the urban African population of the Cape Peninsula, South Africa. The BRISK study. Cent Afr J Med. 1993;39(12):238–247. PMid:8055556

21. Vorster HH, Oosthuizen W, Jerling JC, et al. The nutritional status of South Africans. A review of the literature from 1975–1996. Potchefstroom: Health Systems Trust; 1997.

22. Steyn NP, Myburgh NG, Nel JH. Evidence to support a food-based dietary guideline on sugar consumption in South Africa. Bull World Health Organ. 2003;81(8):599–608. PMid:14576892, PMCid:PMC2572524

23. Vorster HH, Nell TA. Make starchy foods the basis of most meals. S Afr J Clin Nutr. 2001;14(Suppl):S17–S24.

24. Thompson FE, McNeel TS, Dowling EC, et al. Interrelationships of added sugars intake, socioeconomic status, and race/ethnicity in adults in the United States: National Health Interview Survey, 2005. J Am Diet Assoc. 2009;109(8):1376–1383. http://dx.doi.org/10.1016/j.jada.2009.05.002, PMid:19631043, PMCid:PMC2743027

25. Barclay AW, Brand-Miller J. The Australian paradox: a substantial decline in sugars intake over the same timeframe that overweight and obesity have increased. Nutrients. 2011;3(4):491–504. http://dx.doi.org/10.3390/nu3040491, PMid:22254107, PMCid:PMC3257688

26. Hattingh Z, Walsh C, Joubert G. Socio-demographic risk factors for HIV infection in women living in Mangaung, Free State. S Afr J Clin Nutr. 2009;22(4):203–207.

27. MacIntyre UE, Venter CS, Vorster HH. A culture-sensitive quantitative food frequency questionnaire used in an African population: 2. Relative validation by 7-day weighted records and biomarkers. Public Health Nutr. 2001;4(1):63–71. http://dx.doi.org/10.1079/PHN200041, PMid:11315682

28. Hattingh Z, Walsh CM, Veldman FJ, et al. Macronutrient intake of HIV-seropositive women in Mangaung, South Africa. Nutr Res. 2006;26(2):53–58. http://dx.doi.org/10.1016/j.nutres.2005.10.006

29. Hattingh Z, Walsh C, Bester CJ. Anthropometric profile of HIV-uninfected and HIV-infected women aged 25–44 years in Mangaung, Free State. S Afr Fam Pract. 2011;53(5):474–480.

30. Heller M. The DASH Diet Action Plan. Northbrook: Amidan Press; 2010.

31. Hattingh Z, Walsh C, Veldman FJ, et al. The metabolic profiles of HIV-infected and non-infected women in Mangaung, South Africa. S Afr J Clin Nutr. 2009;22(1):23–28.

32. SAS/STATÒ Users’ Guide. Version 9.1. Cary, NC: SAS Institute; 2003.

33. Mollentze WF, Moore AJ, Steyn AF, et al. Coronary heart disease risk factors in a rural and urban Orange Free State black population. S Afr Med J. 1995;85(2):90–96. PMid:7597541

34. Le Roux M, Walsh C, Nel R, et al. The relationship between body mass index, energy intake and level of physical activity of HIV positive women (25–44 years) in Mangaung. Interim. 2005;4(1):93–102.

35. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79(1):6–16. PMid:14684391

36. Drewnowski A. The real contribution of added sugars and fats to obesity. Epidemiol Rev. 2007;29(1):160–171. http://dx.doi.org/10.1093/epirev/mxm011, PMid:17591599

37. Drewnowski A, Darmon N. The economics of obesity: dietary energy density and energy cost. Am J Clin Nutr. 2005;82(1 Suppl):265S–273S. PMid:16002835

38. Bray GA. Fructose: pure, white and deadly? Fructose, by any other name, is a health hazard. J Diabetes Sci Technol. 2010;4(4):1003–1007.

39. Tappy L, Lê KA, Tran C, et al. Fructose and metabolic diseases: new findings, new questions. Nutrition. 2010;26(11–12):1044–1049. http://dx.doi.org/10.1016/j.nut.2010.02.014, PMid:20471804

40. Stanhope KL, Schwarz JM, Keim NL, et al. Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans. J Clin Invest. 2009;119(5):1322–1334. http://dx.doi.org/10.1172/JCI37385, PMid:19381015, PMCid:PMC2673878

41. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84(2):274–288. PMid:16895873, PMCid:PMC3210834

42. Welsh JA, Sharma A, Abramson JL, et al. Caloric sweetener consumption and dyslipidemia among US adults. JAMA. 2010;303(15):1490–1497. http://dx.doi.org/10.1001/jama.2010.449, PMid:20407058, PMCid:PMC3045262

43. Fried SK, Rao SP. Sugars, hypertriglyceridemia, and cardiovascular disease. Am J Clin Nutr. 2003;78(4):873S–880S. PMid:14522752

44. Daly M. Sugars, insulin sensitivity, and the postprandial state. Am J Clin Nutr. 2003;78(4):865S–872S. PMid:14522751

45. Lee RD, Nieman DC. 1996. Nutrition Assessment. 2nd ed. New York: McGraw Hill.

46. Dwyer JT. Dietary assessment.In: Modern nutrition in health and disease. ME Shils, Olson JA, Shike M, Ross AC (editors). 9th ed. p. 597–608. Philadelphia: Lea and Febiger; 1998.